Anesthesia Patient Safety Podcast

#262 Medical Literature Deep Dive: From Infant Intubation to GLP-1 Agonist Risks and More

• Anesthesia Patient Safety Foundation • Episode 262

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Ready for a refreshing summer dive into the latest anesthesia safety research? This episode explores three groundbreaking studies that could transform perioperative practice and patient outcomes.

First, we examine a fascinating randomized clinical trial on "just-in-time" training for inexperienced clinicians performing infant intubations. The results are impressive: trainees who received just 10 minutes of structured training immediately before the procedure achieved a 91.4% first-attempt success rate—significantly better than the 81.6% rate in the standard training group. Could this approach revolutionize how we prepare for all high-stakes medical procedures? The study suggests decreased cognitive load and improved competency with this targeted preparation technique.

Next, we explore a comprehensive meta-analysis of how intravenous antihypertensive medications affect cerebral blood flow. Good news: most medications maintain cerebral autoregulation even when reducing blood pressure. However, nitroprusside and nitroglycerin stand out as exceptions, potentially reducing cerebral perfusion even at appropriate doses. This critical information helps anesthesia professionals make more informed medication choices based on each patient's specific needs.

Finally, we investigate emerging research on GLP-1 receptor agonist medications (increasingly popular for diabetes, weight loss, and cardiovascular disease) and their potential link to vision problems. Several studies suggest these medications may increase the risk of non-arteritic ischemic optic neuropathy—a leading cause of vision loss. While the absolute risk remains small and no direct connection to postoperative vision loss has been established, additional research is needed going forward.

Each of these studies provides valuable insight into how we can continue improving anesthesia safety. Share this episode with your colleagues and join us next time as we work toward ensuring no one is harmed by anesthesia care.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/262-medical-literature-deep-dive-from-infant-intubation-to-glp-1-agonist-risks-and-more/

© 2025, The Anesthesia Patient Safety Foundation

Speaker 1:

You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.

Speaker 2:

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. In some parts of the world it is summer right now and our podcast is giving summer vibes today as we dive into the literature to help cool off. That's right. We will be checking out the in the literature resources from the APSF today, so grab your sunscreen and stay tuned. Before we dive further into the episode today, we'd like to recognize GE Healthcare, a major corporate supporter of APSF. Ge Healthcare has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, ge Healthcare. We wouldn't be able to do all that we do without you.

Speaker 2:

Our first in the literature review is a summary of coaching inexperienced clinicians before a high stakes medical procedure randomized clinical trial. The summary was completed by Mega Kanji and published on APSForg March 3rd 2025. To follow along with us, head over to APpsforg and click on the patient safety resources heading. The eighth one down is in the literature and from here you can scroll down to our featured article. I will include a link in the show notes as well. This summary comes from the article by Flynn and colleagues coaching inexper Inexperienced Clinicians Before a High-Stakes Medical Procedure Randomized Clinical Trial published in the British Medical Journal December 2024. This is such an interesting study and article. You can find the citation in the show notes as well, and we hope that if you have time you'll check out the entire article.

Speaker 2:

The focus of this study is just-in-time training, which is structured training that occurs right before the performance of a task. This is a common approach in other fields. You may have heard musicians warming up before a performance or seen runners doing strides before a race. However, this type of training is rarely used in medicine, but we all know that there are quite a few high-stakes tasks that anesthesia professionals need to be prepared for. The investigators asked the question does providing just-in-time training to trainees before performing high-stakes medical procedures, such as intubating an infant in the operating room, improve outcomes?

Speaker 2:

Here are the study details. It was a non-blinded, randomized clinical trial with 153 trainees, including anesthesiology fellows, anesthesiology residents and student registered nurse anesthetists, who performed 515 intubations. The trainees were randomized to receive either 10 minutes of just-in-time preoperative training on an infant mannequin immediately prior to the intubation, or standard training, which included unstructured interoperative instruction on intubation by the attending anesthesiologist. The primary outcome was first attempt success rate of intubation, and the authors found that just-in-time training increased the likelihood of a successful intubation on the first attempt, with a first attempt success rate of over 91.4%. That is so cool. The standard training group had a first attempt success rate of 81.6%. The secondary outcomes included complication rates, cognitive load related to the intubation and competency. Once again, the just-in-time training revealed positive findings, with evidence of decreased cognitive load and improved competency. Complications were also lower in the just-in-time group, but the difference was not significant in the Just-In-Time group, but the difference was not significant. The author's conclusion is that Just-In-Time training for inexperienced clinicians is an effective way to teach infant intubation skills that may improve patient safety. These results may be more broadly applicable to teaching other high-stakes clinical procedures. Further studies are needed to inform on coaching considerations during the just-in-time training. It will also be important to evaluate if this type of training can be helpful for experienced clinicians as well. The big takeaway from a patient safety perspective is that in this study, the just-in-time training improved the first-pass success rate for a challenging procedure infant intubation while decreasing cognitive load and improving competency, and this could go a long way towards improving anesthesia patient safety, especially during high-stakes procedures with trainees in anesthesiology.

Speaker 2:

Our next featured literature review was published online on April 14, 2025. It is a summary of Impact of Intravenous Antihypertensive Therapy on Cerebral Blood Flow and Neurocognition a systematic review and meta-analysis. The summary was completed by Jayashree Sood and Bhuvan Pandey. The article was published in the British Journal of Anesthesia in January 2025 and written by Meacham and colleagues. You can find the link for the APSF summary, as well as the original article citation in the show notes. Let's get into the summary article citation in the show notes. Let's get into the summary For a bit of background.

Speaker 2:

Intravenous or IV antihypertensives are often administered in the operating room and other acute care settings, but it is unclear what the effects of these medications have on cerebral blood flow and neurocognition. Anesthesia professionals may administer IV antihypertensive medications in the operating theater or recovery room to quickly reduce blood pressure that is severely elevated in order to reduce complications from the too high blood pressure. However, there is a concern that these medications may reduce cerebral blood flow. We need to better understand the effects on cerebral blood flow to help keep patients safe. This is a systematic review and meta-analysis of 50 studies that looked at the effects of different IV antihypertensive medications on cerebral blood flow in humans. Half of these studies evaluated normotensive patients with no intracranial pathology, nine studies focused on patients who were hypertensive and 16 studies focused on patients with intracranial pathology.

Speaker 2:

The medications included in the analysis were nicardipine the most commonly used medication labetalol, nitroprusside and nitroglycerin. When these medications were administered and there was a 20% reduction in mean arterial pressure, or MAP, there was no significant change in cerebral blood flow, and this was true across many different clinical conditions and patient profiles. In addition, for most of the antihypertensive agents, the decrease in MAP did not correspond to any decrease in cerebral blood flow. This is good news that cerebral blood flow autoregulation remains intact following antihypertensive therapy. With most of the medications evaluated in the study, there are some notable exceptions. The administration of nitroprusside or nitroglycerin was associated with a reduction in cerebral blood flow. For awake normotensive patients without intracranial pathology who received these medications, a mean 17% decrease in MAP led to a mean 14% decrease in cerebral blood flow. The authors of the study highlight that nitroprusside and nitroglycerin may impact cerebral perfusion, even when used at appropriate clinical doses. We know from historical data in the 1950s that there may be acute neurocognitive changes associated with significant reductions in MAP of about 58% and cerebral blood flow reductions of about 38%. So we likely need to be careful when administering nitroprusside and nitroglycerin and take into account the clinical context. The study authors share important considerations in their discussion. Iv nicardipine likely maintains tissue perfusion, including cerebral perfusion, due to arteriolar dil, leading to reductions in preload and cardiac output and cardiac output. Further investigations are needed to evaluate blood pressure thresholds and parameters for treatment with IV antihypertensive agents, as well as to determine optimal antihypertensive treatment depending on cerebral perfusion effects, arteriolar or venous dilation effects and impact on end organ perfusion.

Speaker 2:

We hope that you will check out the entire article. Now it's time to move on to our third featured article. This is a summary of glucagon-like peptide 1 receptor agonist medications and non-arteritic ischemic optic neuropathy. Is there cause for concern? This summary was published April 28, 2025 and written by Russell McAllister and Tricia Meyer. There are five references listed below the article. Let's check out the summary now.

Speaker 2:

The focus of this summary is on non-arteritic ischemic optic neuropathy, which is associated with ischemia of the optic nerve and is a leading cause of vision loss, especially in patients over the age of 50. There is still a lot about this condition that we do not understand. There is a very low incidence that is estimated to be about 2 to 10 per 100,000 people. We have been learning more about glucagon-like peptide 1 receptor agonists, or GLP-1 receptor agonists, recently, since there has been increased use for diabetes, weight loss and for reducing morbidity and mortality in patients with cardiovascular disease. There have been a couple of studies and reports in the past year that reveal a possible increased risk of non-arteritic ischemic optic neuropathy in patients who were prescribed a GLP-1 receptor agonist.

Speaker 2:

We are going to look at some of these. First up, a single center retrospective matched cohort study with over 16,000 diabetic patients reported a 4.28-fold increased incidence of non-arteritic ischemic optic neuropathy in patients who were prescribed a GLP-1 receptor agonist compared to those who were taking other diabetes medications those who are taking other diabetes medications. Next, we have a retrospective study published in February 2025 of 14 large healthcare databases with over 37 million patients with diabetes. The investigators found a lower incidence in non-arthritic ischemic optic neuropathy in the patients with type 2 diabetes taking semaglutide. The incidence ratio was 1.32 to 1.5. There was one additional study in Denmark of over 400,000 patients with type 2 diabetes taking once-weekly semaglutide. This was a five-year longitudinal cohort study of all patients with type 2 diabetes in Denmark, the use of semaglutide more than doubled the risk for the development of non-arteric ischemic optic neuropathy. At this time, there is no data that links these findings to any increased risk of postoperative vision loss, but we need to remain vigilant in this area, since ischemic optic neuropathy is a leading cause of postoperative vision loss. There is a careful balance between the risks and benefits, given that there are strong benefits associated with GLP-1 receptor agonist use for the treatment of diabetes, obesity and cardiovascular disease and a very low incidence of non-arthritic ischemic optic neuropathy, the North American Neuro-Optimology Society recommends that patients make no changes in their current use of GLP-1 receptor agonist medications. Going forward, we need more research to determine the true risk of non-arteritic ischemic optic neuropathy in patients taking these medications.

Speaker 2:

Well, that's all the time we have for today. Thank you for joining us for this refreshing literature review. If you have any questions or comments from today's show, please email us at podcast at APSForg. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APpsforg for detailed information and check out the show notes for links to all the topics we discussed today. Thanks for listening. If you get a chance, we hope that you will share this podcast with your colleagues and all of the members of your perioperative team. You can find the Anesthesia Patient Safety Podcast on iTunes, spotify or wherever you get your podcasts, don't forget to subscribe to the show so that you don't miss an episode, as we continue to work towards improved perioperative patient safety. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.